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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- APH = vaginal bleeding ≥24 weeks gestation. Complicates 3–5% of pregnancies
- Major causes: placenta praevia (painless, bright red), placental abruption (painful, dark blood, woody hard uterus)
- Other causes: cervical ectropion, cervical cancer, vasa praevia, trauma
- Assessment: A-E, IV access, FBC/coagulation/crossmatch, CTG, USS for placental localisation
- Never perform digital vaginal examination until placenta praevia excluded by USS
- Management depends on cause, severity, gestation, and maternal/fetal condition
Overview
Antepartum haemorrhage (APH) is defined as bleeding from the genital tract from 24 weeks of gestation until delivery. It complicates 3–5% of pregnancies and is a significant cause of maternal and perinatal morbidity and mortality. The two major obstetric causes are placental abruption and placenta praevia, which together account for approximately half of cases. Other causes include vasa praevia, cervical pathology (ectropion, infection, malignancy), vaginal trauma, and unclassified. In up to 50% of cases, no cause is identified.
Epidemiology
APH complicates 3–5% of all pregnancies. Placental abruption accounts for approximately 30% of significant APH, with an incidence of 0.5–1% of pregnancies. Placenta praevia at delivery occurs in approximately 0.4% of pregnancies. Vasa praevia is rare (1 in 2,500–5,000 pregnancies) but carries a very high fetal mortality if not diagnosed antenatally. Risk factors for APH overlap significantly with those for abruption and praevia individually.
Clinical Features
Symptoms
Vaginal bleeding — painless (suggests praevia) or painful (suggests abruption)
Abdominal pain — constant, severe, suggests abruption
Reduced fetal movements
Uterine contractions or tightening
Symptoms of hypovolaemic shock: dizziness, palpitations, collapse
Signs
Visible vaginal bleeding — may not correlate with total blood loss (concealed haemorrhage in abruption)
Woody hard, tender uterus (abruption — Couvelaire uterus)
High presenting part, abnormal lie (associated with praevia)
Tachycardia, hypotension (significant haemorrhage)
Abnormal CTG — fetal distress or absent fetal heart
Investigations
First-line
Maternal assessmentA-E approach. IV access (2 large-bore cannulae), bloods: FBC, coagulation screen, crossmatch (4 units), U&Es, LFTs
CTGContinuous electronic fetal monitoring — assess fetal wellbeing
UltrasoundPlacental localisation — exclude praevia. NOT reliable for diagnosing abruption (only 50% sensitivity)
Second-line
Kleihauer testQuantifies fetal-maternal haemorrhage — guides anti-D dosing in Rh-negative women
Speculum examinationAfter USS excludes praevia — assess cervix for dilatation, local causes of bleeding
Specialist
MRIRarely needed acutely — may help characterise placental abnormalities in stable patients
1
Immediate assessment
- A-E approach. Establish IV access, send bloods including crossmatch
- Commence continuous CTG for fetal monitoring
- Assess severity: spotting, minor (<50 mL), major (50–1000 mL), massive (>1000 mL or signs of shock)
- DO NOT perform digital vaginal examination until placenta praevia excluded
2
Resuscitation if major/massive
- Aggressive IV fluid resuscitation — crystalloid initially, then blood products
- Activate major obstetric haemorrhage protocol
- Cross-match 4–6 units, consider O-negative blood if critical
- Involve senior obstetrician, anaesthetist, haematologist, and neonatal team
3
Definitive management
- Depends on cause, severity, gestation, and maternal/fetal condition
- If preterm and stable: antenatal corticosteroids (betamethasone 12 mg IM x2, 24 h apart) if <34 weeks
- Anti-D for Rh-negative women — dose guided by Kleihauer test
- Delivery by caesarean section if: massive haemorrhage, fetal distress, or confirmed placenta praevia
- Abruption with fetal death: aim for vaginal delivery if maternal condition stable
Complications
- Maternal: Hypovolaemic shock, DIC, renal failure, death
- Fetal: Prematurity (iatrogenic), hypoxia, IUGR, fetal death
- Postpartum haemorrhage: Increased risk following APH, particularly abruption
- Couvelaire uterus: Blood infiltrates myometrium in severe abruption — may necessitate hysterectomy
UKMLA Exam Tips
- 1Painless bright red bleeding = placenta praevia. Painful dark bleeding with hard uterus = abruption
- 2NEVER perform digital vaginal examination before ultrasound in APH — risk of catastrophic haemorrhage with praevia
- 3Revealed blood loss may not reflect total loss — concealed abruption can cause shock with minimal visible bleeding
- 4Kleihauer test = quantifies fetomaternal haemorrhage — used to guide anti-D dose, not to diagnose abruption
- 5Abruption is a clinical diagnosis — USS is unreliable (only ~50% sensitivity)
practicetest your knowledge on antepartum haemorrhageApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — obstetrics and beyond.
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